Biologic Medications for RA: Actemra, Rituxan, and Orencia

Patient Expert

With nine biologic medications available to treat rheumatoid arthritis, it can be difficult knowing which to choose and how they compare.   Read my previous post - Biologic Medications for RA: The Big Picture - for a run-down of medications including Actemra, Cimzia, Simponi, Rituxan, Orencia, Humira, Kineret, Remicade and Enbrel.

Today, we're comparing Actemra, Rituxan and Orencia which are medications FDA-approved for the treatment of moderate-to-severe rheumatoid arthritis.

The Immune System in RA

The exact cause of rheumatoid arthritis is unknown.   However, RA is most likely triggered by a combination of factors, one of which being an abnormal autoimmune response.   Involved in the inflammation associated with rheumatoid arthritis are B-cells and T-cells, which belong to a class of white blood cells called lymphocytes.

If the T-cell recognizes an antigen as "non-self," it will produce cytokines (such as TNF-alpha, IL-1, or IL-6) which cause B-cells to multiply and release immune proteins (antibodies). These antibodies circulate in the bloodstream, recognizing the foreign particles and triggering inflammation to rid the body of the invasion.   For reasons that are still not completely understood, both the T-cells and the B-cells become overactive in patients with RA.

What do these drugs do?

Each of these drugs interfere with the communication between cells which cause excess inflammation associated with rheumatoid arthritis.   ACTEMRA (tocilizumab) is an interleukin-6 (IL-6) receptor inhibitor.   ORENCIA (abatacept) is a selective costimulation modulator with inhibits T-cell activity.   RITUXAN (rituximab) is a monoclonal antibody therapy which binds to CD20+ B-cells and causes their destruction.

ACTEMRA, RITUXAN and ORENCIA are intended for patients who have had inadequate response from at least one TNF-inhibitor medication (such as Cimzia, Simponi, Humira, Remicade and Enbrel).   Read RA Biologics: Cimzia vs. Simponi for more information.

Dosing Schedule and Delivery

ACTEMRA, ORENCIA and RITUXAN are each given by a healthcare provider (either in your doctor's office, an infusion center, or hospital outpatient center) through a needle placed in a vein (IV or intravenous infusion) in your arm.

For ACTEMRA, the infusion takes about one hour to give you the full weight-based dose of medicine, not to exceed 800mg per infusion.   A reduction of dosage is recommended for management of certain laboratory changes in your blood tests.   You will receive a dose of ACTEMRA about every four weeks.

For ORENCIA, the infusion takes about 30 minutes to give you the full weight-based dose of medicine, not to exceed 1000mg per infusion.   ORENCIA infusions are repeated two weeks and four weeks after the first dose; then you will receive ORENCIA every four weeks.

RITUXAN is used in combination with methotrexate and the first infusion takes about six hours.   One course of treatment consists of two separate 1000mg IV infusions given two weeks apart.   A second course of treatment can be given 24 weeks later (six months), but no earlier than 16 weeks from the previous course.

Glucocorticoids, administered as methylprednisolone 100 mg IV or its equivalent 30 minutes prior to each RITUXAN infusion, are recommended to reduce the incidence and severity of infusion reactions (such as fever and chills).   Premedication with acetaminophen and an antihistamine should also be considered before each infusion.   Your doctor should do regular blood tests to check for side effects to RITUXAN.

For a firsthand account of using RITUXAN, please read my previous posts: Rituximab for RA: My First Experience; Rituxan Infusion: The 2nd Time is Easier than the First; and Navigating Costs and Insurance for Rituxan.

Common Side-Effects

Common side effects of ACTEMRA include: upper respiratory tract infections (common cold, sinus infections); headache; and increased blood pressure (hypertension).   Serious allergic reactions which may not happen with your first infusion, but with future infusions.

Common side effects of ORENCIA in both adults and children include: headache, upper respiratory tract infection, sore throat, nausea.   In children, other side effects may include: diarrhea, cough, fever, abdominal pain.

Common side effects during RITUXAN infusions include: fever, headache, chills and shakes, nausea, itching, hives, cough, sneezing, throat irritation or tightness.   Other side effects with RITUXAN include: aching joints, upper respiratory tract infection, decreased blood cell counts, and lung problems.

More Serious Side-Effects

ACTEMRA can cause serious side effects including: serious infections including tuberculosis (TB), and other infections caused by viruses, bacteria, or fungi; reactivation of the Hepatitis B virus; nervous system problems such as multiple sclerosis; tears (perforation) of the stomach or intestines; and changes in certain laboratory test results including low neutrophil count, low platelet count, or an increase in certain liver function tests.   You may have changes in other laboratory tests, such as your blood cholesterol levels which should be checked four to eight weeks after you start receiving ACTEMRA.

ORENCIA can cause serious side effects including: serious infections including pneumonia, and other infections caused by viruses, bacteria, or fungi; allergic reactions on the day of treatment or the day after receiving ORENCIA; cancer (malignancies); respiratory problems in patients with Chronic Obstructive Pulmonary Disease (COPD).

RITUXAN can cause serious side effects including: progressive multifocal leukoencephalopathy (PML), a rare brain infection which can cause death or severe disability in patients with weakened immune systems; infusion reactions, such as hives, swelling, dizziness, blurred vision, drowsiness, headache, cough, wheezing, or trouble breathing; severe skin reactions; reactivation of the Hepatitis B virus; heart problems; or infections.

In patients with non-Hodgkin's lymphona, RITUXAN can cause tumor lysis syndrome (TLS) which is caused by the fast breakdown of certain types of cancer cells. TLS can cause kidney failure and the need for dialysis treatment.   Serious stomach and bowel problems have been seen in some non-Hodgkin's lymphoma patients treated with anti-cancer medications.

When taking any of these biologic medications for the treatment of rheumatoid arthritis, it is important that you do not receive live vaccines.

Please read the ACTEMRA Medication Guide, the RITUXAN Medication Guide, and the ORENCIA Medication Guide for further information.

If you have direct experience using either Actemra, Rituxan or Orencia, please share in the comments section.   Thanks.

Click here to view a spreadsheet I created detailing and comparing the nine biologic medications prescribed for RA.